DIABETESCH 49

BRITTANY BRELSFORD SI

1. IN ADDITION TO PROMOTING THE TRANSPORT OF GLUCOSE FROM THE BLOOD INTO THE CELL, WHAT DOES INSULIN DO?

A. Enhances the breakdown of adipose tissue for energy

B. Stimulates hepatic glycogenolysis and gluconeogenesis

C. Prevents the transport of triglycerides into adipose tissue

D. Accelerates the transport of amino acids into cells and their synthesis into protein

ANSWER: D

• INSULIN IS AN ANABLIC HORMONE THAT IS RESPONSIBLE FOR GROWTH, REPAIR, STORAGE. It facilitates movement of amino acids into cells, synthesis of protein, storage of glucose as glycogen, and deposition of triglycerides and lipids as fat into adipose tissue. Glucagon is responsile for hepatic glycogenolysis and gluconeogenesis. Fat is used for energy when glucose levels are depleted

2. WHICH TISSUES REQUIRE INSULIN TO ENABLE MOVEMENT OF GLUCOSE INTO THE TISSUE CELLS?SELECT ALL THAT APPLY

A. LIVER

B. BRAIN

C. ADIPOSE

D. BLOOD CELLS

E. SKELETAL MUSCLE

ANSWER: C,E

• Adipose tissue and skeletal muscle require insulin to allow the transport of glucose into the cells. Brain, liver, and blood cells require adequate glucose supply for normal function but do not depend on insulin for glucose transport

3. WHY ARE THE HORMONES CORTISOL, GLUCAGON, EPINEPHRINE, AND GROWTH HORMONE REFERRED TO AS COUNTER REGULATORY HORMONES?

A. DECREASE GLUCOSE PRODUCTION

B. STIMULATE GLUCOSE OUTPUT BY THE LIVER

C. INCREASE GLUCOSE TRANSPORT INTO THE CELLS

D. INDEPENDENTLY REGULATE GLUCOSE LEVEL IN THE BLOOD

ANSWER: B

• THEY HAVE THE OPPOSITE EFFECT OF INSULIN BY STIMULATING GLUCOSE PRODUCTION AND OUTPUT BY THE LIVER AND BY DECREASING GLUCOSE TRANSPORT INTO THE CELLS. TOGETHER, INSULIN AND THE COUNTER REGULATORY HORMONES REGULAR BLOOD GLUCOSE LEVEL

4. WHAT CHARACTERIZES TYPE 2 DIABETES? SELECT ALL THAT APPLY

A. Beta cell exhaustion

B. Insulin resistance

C. Genetic predisposition

D. Altered production of adipokines

E. Inherited defect in insulin receptors

F. Inappropriate glucose production by the liver

ANSWER: A,B,C,D,E,F

5. WHICH LAB TEST WOULD INDICATE THAT THE PATIENT HAS PREDIABETES?

A. Glucose tolerance result of 132 mg/dL

B. Glucose tolerance result of 240 mg/dL

C. Fasting blood glucose result of 80 mg/dL

D. Fasting blood glucose result of 120 mg/dL

ANSWER: D

• PREDIABETES IS DEFINED AS IMPAIRED GLUCOSE TOLERANCE, IMPAIRED FASTING GLUCOSE, OR BOTH. FASTING BLOOD GLUCOSE INBETWEEN 100 AND 125 MG/DL INDICATE PREDIABETES.

• A diagnosis of impaired glucose tolerance is made if the 2-hour OGTT results are between 140 and 199 mg/dL

6. THE NURSE IS TEACHING THE PATIENT WITH PREDIABETES WAYS TO PREVENT OR DELAY THE DEVELOPMENT OF TYPE 2 DIABETES. WHAT INFO SHOULD BE INCLUDED? SELECT ALL THAT APPLY

A. Maintain a healthy weight

B. Exercise for 60 minutes each day

C. Have blood pressure checked regularly

D. Assess for visual changes on a monthly basis

E. Monitor for polyphagia, polydipsia, polyuria

ANSWER: A, E

• To reduce the risk of developing diabetes, the patient with prediabetes should learn to monitor for symptoms of diabetes, have blood glucose and glycosylated hemoglobin (A1C) tested regularly, maintain a healthy weight, exercise regularly, and eat a healthy diet.

7. IN TYPE 1 DIABETES THERE IS AN OSMOTIC EFFECT OF GLUCOSE WHEN INSULIN DEFICIENCY PREVENTS THE USE OF GLUCOSE FOR ENERGY. WHICH CLASSIC SYMPTOM IS CAUSED BY THE OSMOTIC EFFECT OF GLUCOSE?

A. fatigue

B. Polydipsia

C. Polyphagia

D. Recurrent infections

ANSWER: B

• Polydipsia is caused by fluid loss from polyuria when high glucose levels cause osmotic diuresis. Cellular starvation from lack of glucose and the use of body fat and protein for energy contribute to fatigue, weight loss, and polyphagia in type 1

8. WHICH PATIENT SHOULD THE NURSE PLAN TO TEACH HOW TO PREVENT OR DELAY THE DEVELOPMENT OF DIABETES?

A. An obese 50 year old Hispanic woman

B. A child whose father has type 1

C. A 34 year old woman whose parents both have type 2 diabetes

D. A 12 year old boy whose father has maturity onset diabetes of the young (MODY)

ANSWER: C

• Type 2 diabetes has a strong genetic influence and offspring of parents who both have type 2 have an increased chance of developing it.

9. WHEN CARING FOR A PATIENT WITH METABOLIC SYNDROME, WHAT SHOULD THE NURSE GIVE THE HIGHEST PRIORITY TO TEACHING THE PATIENT ABOUT?

A. Achieving a normal weight

B. Performing daily aerobic exercise

C. Eliminating red meat from the diet

D. Monitoring the blood glucose periodically

ANSWER: A

• Metabolic syndrome is a cluster of abnormalities that include elevated glucose levels, abdominal obesity, elevated blood pressure, high levels of triglycerides, and low levels of HDLs. Overweight individuals with metabolic syndrome can prevent or delay the onset of diabetes through a program of weight loss. Exercise is also important but normal weight is most important.

10. DURING ROUTINE HEALTH SCREENING, A PATIENT IS FOUND TO HAVE FASTING PLASMA GLUCOSE (FPG) OF 132 MG/DL. AT A FOLLOW-UP VISIT, A DIAGNOSIS OF DIABETES WOULD BE MADE BASED ON WHICH LAB RESULTS? SELECT ALL THAT APPLY

A. A1c of 7.5%

B. Glycosuria of 3+

C. FPG at or greater than 126 mg/dL

D. Random blood glucose of 126mg/dL

E. A 2 hour OGTT of 190 mg/dL

ANSWER: A, C

• The patient has one prior test result that meets criteria for a diagnosis of diabetes but this test must be confirmed on a subsequent day. The A1C is greater than 6.5% so it also indicated diabetes according to criteria for diagnosis. These criteria include a fasting plasma glucose (FPG) level greater than 126 mg/dL, A1C greater than 6.5%, or a 2 hour OGTT level greater than 200 mg/dL, or in a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose greater than 200 mg/dL.

11. THE NURSE DETERMINES THAT A PATIENT WITH A 2-HOUR OGTT OF 152 MG/DL HAS…

A.DiabetesB.Elevated A1CC.Impaired fasting glucoseD.Impaired glucose tolerance

ANSWER: D

• Impaired glucose tolerance exists when a 2 hour OGTT level I higher than normal but lower than the level diagnostic for diabetes (>200). Impaired fasting glucose exists when fasting glucose levels are greater than the normal 100 mg/dL but less than the 126 mg/dL diagnostic for diabetes. Both abnormal values are diagnostic for prediabetes.

12. WHEN TEACHING THE PATIENT WITH DIABETES ABOUT INSULIN ADMINISTRATION, THE NURSE SHOULD INCLUDE WHICH INSTRUCTION FOR THE PATIENT?

A. Pull back on the plunger after inserting the needle to check for blood

B. Consistently use the same size of insulin syringe to avoid dosing errors

C. Clean the skin at the injection site with an alcohol swab before each injection

D. Rotate injection sites from arms to thighs to abdomen with each injection to prevent lipodystrophies

ANSWER: B

• Errors can be made in dosing if patients switch back and forth between different sizes of syringes. U100 insulin must be used with a u100 syringe, but for those using low doses of insulin, syringes that have increments of 1 or 2 units are available.

13. A PATIENT WITH TYPE 1 USES 20 U OF 70/30 NEUTRAL PROTAMINE HAGEDORN (NPH/REGULAR) IN THE MORNING AND AT 6 PM. WHICH TEACHING THE PATIENT ABOUT THIS REGIMEN, WHAT SHOULD THE NURSE EMPHASIZE?

A. Hypoglycemia is most likely to occur before the noon meal

B. Flexibility in food intake is possible because insulin is available 24 hours a day

C. A set meal pattern with a bedtime snack is necessary to prevent hypoglycemia

D. Premeal glucose checks are required to determine needed changes in daily dosing

ANSWER: C

• A split-mixed dose of insulin requires that the patient adhere to a set meal pattern to provide glucose for the peak action of the insulin and a bedtime snack is usually required when patients take an intermediate-acting insulin late in the day to prevent nocturnal hypoglycemia. Hypoglycemia is most likely to occur with this dose late in the afternoon and during the night. When premised formulas are used, flexible dosing based on glucose levels is not recommended.

14. LISPRO INSULIN (HUMALOG) WITH NPH INSULIN IS ORDERED FOR A PATIENT WITH NEWLY DIAGNOSED TYPE 1 DIABETES. THE NURSE KNOWS THAT WHEN LISPRO INSULIN IS USED, WHEN SHOULD IT BE ADMINISTERED?

A. ONLY ONCE A DAY

B. 1 HOUR BEFORE MEALS

C. 30-45 MINUTES BEFORE MEALS

D. AT MEALTIME OR WITHIN 15 MINUTES OF MEALS

ANSWER: D

• LISPRO IS A RAPID-ACTING INSULIN THAT HAS AN ONSET OF ACTION OF ABOUT 15 MINUTES AND SHOULD BE INJECTED AT THE TIME OF THE MEAL TO ITHIN 15 MINUTES OF EATING. REGULAR INSULIN IS SHORT ACTING WITH AN ONSET OF ACTION IN 30-60 MINUTES

15. WHICH INTERVENTION CAN THE NURSE DELEGATE TO THE UNLICENSED ASSISTIVE PERSONNEL (UAP)?

A. Discuss complications of diabetes

B. Check that the bath water is not too hot

C. Check the patient’s technique for drawing up insulin

D. Teach the patient to use a meter for self-monitoring of blood glucose

ANSWER: B

• Checking the temperature of the bath water is part of assisting with the activities of daily living (ADLs) and within the scope of care for unlicensed assistive personnel (UAP). This is important for the patient with neuropathy. Discussion of complications, teaching, and assessing learning are appropriate for RN’s.

16. THE HOME CARE NURSE SHOULD INTERVENE TO CORRECT A PATIENT WHOSE INSULIN ADMINISTRATION INCLUDES:

A. Warming a prefilled refrigerated syringe in the hands before administration

B. Storing syringes prefilled with NPH and regular insulin needle-up in the refrigerator

C. Placing the insulin bottle currently in use in a small container on the bathroom countertop

D. Mixing an evening dose of regular insulin with insulin glargine in one syringe for administration

ANSWER: D

• Insulin glargine (Lantus) is a long acting insulin that is continuously released with no peak of action and cant be diluted or mixed with any other insulin or solution. Mixed insulins should be stored needle-up in the refrigerator and warmed up before administration. Bottles currently in use can be kept at room temperature out of sunlight.

17. A PATIENT WITH DIABETES IS LEARNING TO MIX REGULAR INSULIN AND NPH INSULIN IN THE SAME SYRINGE. THE NURSE DETERMINES THAT ADDITIONAL TEACHING IS NEEDED WHEN THE PATIENT DOES WHAT?

A. Withdraws the NPH dose into the syringe first

B. Injects air equal to the NPH dose into the NPH vial first

C. Removes any air bubbles after withdrawing the first insulin

D. Adds air equal to the insulin dose into the regular vial and withdraws the dose

ANSWER: A

• When mixing regular and intermediate-acting insulin, regular should always be drawn into the syringe first to prevent contamination of the regular insulin vial with the intermediate-acting additives. Air is added to the NPH vial. Then air is added to the regular vial and the regular insulin is withdrawn, bubbles are removed, and the dose of NPH is withdrawn.

18. WHAT ARE THE MANIFESTATIONS OF DIABETIC KETOACIDOSIS (DKA)? SELECT ALL THAT APPLY

A. Thirst

B. Ketonuria

C. Dehydration

D. Metabolic acidosis

E. Kussmaul respirations

F. Sweet, fruity breath odor

ANSWER: A, B, C, D, E, F

• In DKA, ketosis leads to ketonuria in trying to decrease the blood glucose and ketonemia. Metabolic acidosis leads to kussmauls respirations to try and decrease the acid in the system. The sweet fruity breath odor is from DKA. Thirst and dehydration are found in both DKA and hyperosmolar hyperglycemic syndrome (HHS)

19. THE PATIENT WITH NEWLY DIAGNOSED DIABETES IS DISPLAYING SHAKINESS, CONFUSION, IRRITABILITY, AND SLURRED SPEECH. WHAT SHOULD THE NURSE SUSPECT IS HAPPENING?

A. DKA

B. HHS

C. Hypoglycemia

D. Hyperglycemia

ANSWER: C

• Hypoglycemia causes epinephrine to be released which contributes to shakiness and irritability. Without glucose in the brain, the patient may have difficulty speaking, stupor, visual disturbances, confusion, or coma. It is better to treat for hypoglycemia when unsure of the actual blood glucose level

20. A PATIENT HAS A BLOOD GLUCOSE LEVEL OF 248 MG/DL. WHICH MANIFESTATIONS IN THE PATIENT WOULD THE NURSE UNDERSTAND AS BEING RELATED TO THIS BLOOD GLUCOSE LEVEL? SELECT ALL THAT APPLY

A. Headache

B. Unsteady gait

C. Abdominal cramps

D. Emotional changes

E. Increase in urination

F. Weakness and fatigue

ANSWER: A, C, E, F

• Manifestations of hyperglycemia include abdominal cramps, polyuria, weakness, fatigue, and headache. Headache can also be seen with hypoglycemia

21. THE NURSE IS ASSESSING A NEWLY ADMITTED DIABETIC PATIENT. WHICH OBSERVATION SHOULD BE ADDRESSED AS THE PRIORITY BY THE NURSE?

A. Bilateral numbness of both hands

B. Stage II pressure ulcer on right heel

C. Rapid respirations with deep inspiration

D. Areas of lumps and dents in the abdomen

ANSWER: C

• Rapid, deep respirations are symptoms of DKA so this is the priority of care. Stage II pressure ulcers and bilateral numbness are chronic complications of diabetes. The lumps and dents on the abdomen indicate a need to teach the patient about site rotation.

22. A DIABETIC PATIENT IS FOUND UNCONSCIOUS AT HOME AND A FAMILY MEMBER CALLS THE CLINIC. AFTER DETERMINING THAT A GLUCOMETER IS NOT AVAILABLE, WHAT SHOULD THE NURSE ADVISE THE FAMILY MEMBER TO DO?

A. Have the patient drink some orange juice

B. Administer 10 U of regular insulin sub-Q

C. Call for an ambulance to transport the patient to a medical facility

D. Administer glucagon 1 mg IM or sub-Q

ANSWER: D

• If a diabetic patient is unconscious, immediate treatment for hypoglycemia must be given to prevent brain damage and IM or subQ administration of 1 mg of glucagon should be done. If the unconsciousness has another cause such as ketosis, the rise in glucose caused by glucagon is not as dangerous as the low glucose level. Following administration of the glucagon, the patient should be transported to a medical facility for further treatment and evaluation. Insulin is contraindicated without knowledge of the patient’s glucose level and oral carbohydrates cannot be given to an unconscious patient.

23. WHICH CLASS OF ORAL GLUCOSE-LOWERING AGENTS IS MOST COMMONLY USED FOR PEOPLE WITH TYPE 2 DIABETES BECAUSE IT REDUCES HEPATIC GLUCOSE PRODUCTION AND ENHANCES TISSUE UPTAKE OF GLUCOSE?

A. Insulin

B. Biguanide

C. Meglitinide

D. Sulfonylurea

ANSWER: B

• Biguanides (metformin [Glucophage]) are most commonly used with type 2 diabetes. They reduce glucose production by the liver and increase insulin sensitivity at the tissue level that improves glucose transport into the cells. Insulin is not taken orally as it is ineffective. Meglitinides and sulfonylureas increase insulin production from the pancreas.

24. WHAT DISORDERS AND DISEASES ARE RELATED TO MACROVASCULAR COMPLICATIONS OF DIABETES? SELECT ALL THAT APPLY

A. Chronic kidney disease

B. Chronic artery disease

C. Micro aneurysms and destruction of retinal vessels

D. Ulceration and amputation of the lower extremities

E. Capillary and arteriole membrane thickening specific to diabetes

ANSWER: B, D

• Macrovascular disease causes coronary artery disease and ulceration and results in amputation of the lower extremities. However, neuropathy may also contribute to not feeling ulcerations. The remaining options are related to microvascular complications of diabetes.

25. FOLLOWING THE TEACHING OF FOOT CARE TO A DIABETIC PATIENT, THE NURSE DETERMINES THAT ADDITIONAL INSTRUCTION IS NEEDED WHEN THE PATIENT MAKES WHICH STATEMENT?

A. “I should wash my feet daily with soap and warm water”

B. “I should always wear shoes to protect my feet from injury”

C. “if my feet are col I should wear socks instead of using a heating pad”

D. “I’ll know I have sores or lesions on my feet because they will be painful”

ANSWER: D

• Complete or partial loss of sensitivity of the feet is common with peripheral neuropathy of diabetes and patients with diabetes may suffer foot injury and ulceration without ever having pain. Feel must be inspected during daily care for any cuts, blisters, swelling, or reddened areas.